Many healthcare judgments are made in situations of uncertainty where assessments and decisions are based on information that is incomplete, made under time pressure and in an emotional atmosphere. This study examined one such situation, the decision to transfer a woman in labour from a community maternity unit to a specialist obstetric unit; a decision which is central to the provision of high quality, safe maternity care in rural areas.
The study found that when presented with the same case factors participants made similar judgments about women’s suitability to remain in midwife led care. In the first stage of the study midwives and obstetricians described a wide range of clinical and contextual factors which they reported taking into account in deciding whether to transfer a woman in labour to specialist obstetric facilities, including the woman’s preference for place of birth, impact on the family, workload, the attitude of the receiving unit, and travel time. However, subsequent analysis of the vignette task using SJT found that clinical factors dominated the assessment, with one key factor, concern over wellbeing of the fetus clearly paramount; contextual issues appeared to play little part. Other studies have reported a perceived lack of understanding between midwives working in different settings
[14, 16, 17], and this issue was raised in stage one. However, the vignette analysis found that, regardless of professional group or setting, clinicians made similar case assessments, using the same case factors and weighing them similarly.
Despite making very similar case assessments, there were significant differences in the decisions that were made. Distance was an influencing factor, midwives working in units which were more distant from acute service provision made significantly more decisions to transfer and were more willing to transfer cases than midwives working in near or alongside midwife led units, or obstetricians. More surprising, was the wide range of transfer decisions that were made within all groups. For example, while one midwife (from a distant unit) decided to transfer only 25% percent of cases another midwife, within the same group, would have transferred 93%. The largest differences were found in the obstetrician’s group where the range was 1-96% of cases. This may be partly explained by the relative unfamiliarity of the task for the obstetricians, as within the UK they invariably receive transferred cases and will not have personal experience of making the decision to transfer from a rural maternity unit. From our findings it appears that variations in transfer decision making lie not in the clinicians risk assessments but in their risk tolerance and personal decision thresholds, and that this is exacerbated by distance from acute care.
The quality and safety of rural maternity care is an issue of continuing debate in particular in developed counties with extensive remote and rural areas, for example, Canada and Australia. However, within geographically smaller countries such as the UK the principle issues of concern are the same, despite the smaller distances involved. Much of the research on rural maternity care has focussed on clinical and economic outcomes
[3, 14, 32–34] and on the clinical skills, and competence of healthcare providers
[9, 16]. As a result there has been a focus on provision of guidelines and training strategies targeting maintenance of skills and improvement of clinical assessments. Clinical knowledge and competence are clearly essential aspects of high quality healthcare however, the findings of the current study suggest that clinicians across a range of settings have the ability to make good clinical asessments and that the clinician’s personal decision threshold is more influential.
Decision thresholds are determined by an individual’s values and their utilities for the consequences of their decisions. Studies reporting the experiences of rural clinicians highlight why this may be an issue of particular relevance for rural maternity care. Practitioners have reported feelings of personal responsibility for sustainability of local services, and for the consequencies of poor clinical outcomes
[16, 17]. These experiences are exacerbated by the visability of healthcare workers within local communities and by feelings of isolation and lack of understanding and support from colleagues working in urban referral centers
[14, 16, 17, 33]. Maternity care practitioners are acutely aware of the risks and uncertainties inherent in their judgments and decisions, and of the high stake, long term consequences both for themselves and the communities they serve.
This is the first study which has focussed specifically on the judgment and decision making performance of rural healthcare providers, using a model informed by decision making theory. It provides an explanation for the wide range of decisions made against a background of similar clinical assessment. Key to the model is the notion that the factors influencing the assessment of a case are different to those influencing the placement of the decision threshold. Overall, clinicians appear to take into account the same pieces of case information and combine these data in similar ways; it appears that the “scales” used in making case assessments are similar, however, their decision cut off points are different. If a clinician has a low decision threshold then they would take action (transfer) even if they assessed a case to have low risk. Conversely, if the threshold was high, then they would take action only if the risk assessment is high. Consequently, even if two clinicians agree on the amount of risk in a case, they may disagree about the course of action because their tolerance for acceptable risk differs.
These findings have important implications for clinical practice. In some situations the decision task may be relatively clear cut, objective diagnostic measures may be available for the assessment along with strong, evidence based guidelines for clinical management. An example would be hypertension in pregnancy where a blood pressure recording above a specific threshold will trigger a medical referral in the majority of cases. However, in many clinical situations uncertainty characterises both the assessment and the decision. In these cases there will always be the need for clinicians to exercise professional judgment, increasing the likelihood of variation, yet consistency is considered to be one of the key markers of quality healthcare. While consistency is not a guarantee of good decision making (clinicians could be consistently wrong) inconsistent decisions must, at best, be correct only some of the time. The response to inconsistency or apparent error in clinical decision making is often to introduce guidelines or to undertake case reviews. However, where clinicians do not differ, or do not differ by very much in their case assessments, retrospectively reviewing cases, or trying to improve consistency of clinical assessment by introducing guidelines (in particular guidelines based chiefly on professional consensus) is unlikely to identify the source of disagreement or increase consistency of decision making.
There has been little research on possible means of adjusting decision thresholds and more applied research in this area is required. Decision thresholds are affected by experiences both personal and vicarious; thresholds may change gradually over time or shift rapidly in response to traumatic events. Such events may remain vivid in the memory for long periods and may even be passed down in the ‘folk memory’ of a hospital. While it is not easy for people to choose to change the values they attach to consequences which have been shaped by past experience and history, understanding the sources of decision conflict and provision of peer support may provide the opportunity to bring decisions closer together. The reverse is also likely to be true where punitive responses to clinical error may have the effect of lowering decisional threshold rather than improving clinical assessments.
The use of vignettes cannot fully replicate the real life clinical situation where judgments and decisions are rarely made in isolation. However it allows the presentation of same case factors to all participants, a situation which cannot be replicated in real life. The ecological validity of the vignettes was maximised by extracting data from a large number of cases described by clinicians and extensive piloting of vignettes and training materials. Further, although the vignettes were abstract in form the decision task was very familiar to the midwife participants, less so for the obstetricians. The rigorous sampling method used means that the study findings are likely to be representative of midwives providing rural maternity care across Scotland although this is less likely to be the case for the obstetricians where purposive sampling was used and smaller numbers were involved. Nevertheless, the study involved a large clinically relevant sample, this contrasts with many decision making studies which are often characterised by small, student samples.